Health Assessment Exam1: Study Guide Health Assessment Exam1: Study Guide, Exams of Nursing

Download Health Assessment Exam1: Study Guide Health Assessment Exam1: Study Guide and more Exams Nursing in PDF only on Docsity! Final Exam Review-Rationales 1. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic b. Black c. Asian d. American Indian Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups. 2. When planning a cultural assessment, the nurse should include which component? a. Family history-history b. Chief complaint-history c. Medical history- history d. Health-related beliefs -cultural 3. During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question 4. The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off television and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less—should be 4-5 feet c. Provides a dim light that makes the room cozy and helps the patient relax-well lit d. Arranges seating across a desk or table to allow the patient some personal space- equal status seating at eye level is better 5. When the nurse is evaluating the reliability of a patients responses, which of these statements would be correct? The patient: a. Has a history of drug abuse and therefore is not reliable b. Provided consistent information and therefore is reliable c. Smiled throughout interview and therefore is assumed reliable d. Would not answer questions concerning stress and therefore is not reliable A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. 6. Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin? a. Skin appears dry- objective, what the nurse observes b. No lesions are obvious- objective c. Patient denies any color change- subjective is what patient says d. Lesion is noted on the lateral aspect of the right arm – objective 7. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm. 8. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla- A bulla is larger than 1 cm, superficial, and thin walled. b. Wheal- A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. c. Nodule- A nodule is solid, elevated, hard or soft, and larger than 1 cm. d. Papule- A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. 9. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the and glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable. 10. The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patients body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patients temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment observing the patients physical appearance, body structure, mobility, and behavior. 11. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light b. Light is reflected at the same spot in both eyes c. The eye focuses the image in the center of the pupil d. Constriction of both pupils occurs in response to bright light 12. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a. Light pink with a slight bulge b. Pearly gray and slightly concave c. Pulled in at the base of the cone of light d. Whitish with a small fleck of light in the superior portion 13. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Inserting the speculum at least 3 cm into the vestibule b. Avoiding touching the nasal septum with the speculum c. Gently displace the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum. 14. A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of: a. A problem with the patients coagulation system b. Increased vascularity in the upper respiratory tract as a result of pregnancy c. Increased susceptibility to colds and nasal irritation d. Inappropriate use of nasal sprays 15. Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly b. Extend 3-4 cm above the inner third of the clavicle c. Are located at the sixth rib anteriorly and eight rib laterally d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7. 16. If you are examining a patient with asthma, which breath sounds would you hear?